Gastroenterologist Realizes the Gut Is Not Enough

Field's curiosity about psychodynamics was also enhanced by the discovery that the gut uses the same neurotransmitters as the central nervous system and by the fact that new therapies for irritable bowel syndrome (as for anxiety and depression) target neurotransmitters, specifically serotonin. Serotonin is a major regulator of gut motility, he pointed out.

Finally, Field came to realize that he wanted to care for gastrointestinal patients using both psychological and medical expertise.

So in 2002, he asked the chair of psychiatry at New York University what it would entail if he retrained in psychiatry. During this conversation, the chair suggested that since Field was more interested in psychodynamics than in brain neurotransmitters, he might consider studying at the New York University Psychoanalytic Institute.

“One of my perceptions was that mainstream psychiatry, certainly in New York City, is more biologically than psychoanalytically oriented,” Field said. “Thus, I felt that psychoanalysis rather than psychiatry would probably be a better choice for me.”

Field contacted the New York University Psychoanaly tic Institute and arranged an interview; shortly after, he was accepted. The institute has two tracks—a purely analytic one that takes four years and a psychodynamic psychotherapy one that takes two years. Field opted for the latter. “I wanted to get to the basics and then put them into practice as soon as possible,” he explained.

From 2002 to 2004 Field took didactic courses in psychodynamic psychotherapy in the evening while continuing with his gastroenterology practice. The director of his program, Seth Eichler, M.D., was especially supportive and helpful, he noted. “The institute was in a funny position with my candidacy, because it usually trains mental health providers, and I am not one. So a whole series of things had to be done.”

For example, institute leaders arranged a tutorial for him in basic areas of psychopathology to flesh out the curriculum a bit. And while students at the institute usually practice analysis or psychodynamic psychotherapy with their own patients, Field was not able to do that with his gastroenterology patients because of boundary issues.

“I mean, I am these people's doctor, I examine them with their clothes off, I do all sorts of intrusive things to them,” he commented wryly. But fortunately some of his medical colleagues referred a few psychotherapy patients to him with whom he could work under supervision.“ Currently, I have two patients in supervised psychodynamic psychotherapy,” he said.

Although Field is not yet a full-fledged psychotherapist, he has learned some fascinating things from his psychodynamic courses.

“In medicine—in internal medicine certainly—there is a sharp line between what is normal and what is pathological. So I was surprised to learn that many of the traits you find in people with personality disorders are really dysfunctional exaggerations of things lots of perfectly normal people think about, have, or do on a daily basis.

“Also, many people believe that in conducting psychotherapy, all you have to do is listen. But of course it's not that easy, I've found. I have a particular style with patients that I have developed over 25 years in medical practice. It involves a significant degree of interactivity, with me sometimes almost finishing patients' sentences for them. But in a formal psychodynamic encounter, as your readers well know, you have to have a lot more patience, you have to be able to sit there and let patients come to a lot of their own conclusions.”

As he steadily broadens his knowledge about psychodynamic practices and principles, he is already applying what he has learned to his gastroenterology practice.

For example, he has found that his psychotherapy training is especially helpful in treating patients with irritable bowel syndrome since anxiety, depression, childhood physical abuse, or childhood sexual abuse are among factors that can be linked to the syndrome. He has also found it helpful to some extent in treating patients with inflammatory bowel disease. While he noted that there is no solid evidence that this illness is caused by psychological factors, it tends to strike young adults and be chronic.“ So there are many psychological issues that arise when young, otherwise healthy adults have a chronic illness.”

He is also tapping his new font of knowledge when gastrointestinal patients are sent to him for a second opinion. “I review everything medical, but I also listen to them with a psychotherapeutic ear now. This way they often feel that a physician understands more about them even if no one has come up with a specific medical diagnosis.”

One particularly valuable aspect that Field has taken from his new erudition is being able to identify gastroenterology patients who would benefit from psychotherapy and to help them obtain it.

“I have told certain patients that it is very important for them to see a psychotherapist if they really want to see their condition improve as much as possible,” he said. “Many have followed my advice.”

And those who have followed his advice appear to have profited from the therapy they received, he added.

Asked how he anticipates using his psychodynamic training over the next several years, Field gave a light laugh. “What I would like to do is... well, it is still sort of a work in progress. At one point I actually thought that there might be a time where I would want to do psychoanalysis rather than gastroenterology. But I like what I do. I like general medicine, and I like GI a lot. So I think I'll use it in GI patient care. For instance, some gastroenterologists are starting to refer patients to me where they suspect that the patient's GI problems have a strong psychological component. I'm also flirting with the idea of working with a psychotherapist—having a collaborative practice.”

And, said Field, who is a clinical assistant professor of medicine at New York University as well as a private practitioner, “I think it would be great to launch an educational initiative that exposes medical students and house staff to some of the concepts of psychodynamic treatment. I think it would make physicians more complete physicians, more able to care for the whole patient.” ▪